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I HUMAN CASE WEEK #7 (CLASS 6512) 18 YEAR OLD
PATIENT REASON FOR ENCOUNTER: PASSED OUT I
HUMAN CASE ASSESMENT 2025
Patient Presentation: An 18-year-old male, accompanied by his father,
presents to the clinic post-exercise collapse with transient loss of consciousness
on the football field during practice. Symptoms include headache, nausea,
lightheadedness, cramps, excessive sweating, and decreased urination,
exacerbated by inadequate hydration. Physical examination reveals tachycardia,
orthostatic hypotension, dry mucous membranes, and a capillary refill of 3
seconds. Risk factors include antihistamine use, alcohol, wearing heavy
equipment in high heat, humidity, and obesity.
Primary Diagnosis: Heat Exhaustion: The leading diagnosis is heat
exhaustion, indicated by a heat index of 100°F, insufficient hydration, high-
intensity exercise, and loss of consciousness. Differentiated from simple
dehydration by the heat index, the patient’s sweating, normal mentation, and
core body temperature below 104°F disqualify heat stroke (Mayo Clinic, 2021).
Differential Diagnoses:
1. Bradycardia:
Signs include fatigue, fainting, lightheadedness, confusion, or chest pain
(O’Connor and Casa, 2021).
Absence of chest pain and shortness of breath rules out bradycardia.
1. Syncope:
Symptoms involve blacking out, falling, lightheadedness, dizziness, fainting,
and changes in vision (O’Connor and Casa, 2021).
Absence of grogginess excludes syncope.
1. Dehydration:
Symptoms include tiredness, headache, lightheadedness, dry mouth, and
infrequent urination (O’Connor and Casa, 2021).
Patient exhibited all dehydration symptoms.
Pharmacological Care:
No intervention if stable, continuous monitoring for patient safety.
Cardiac monitoring, IV access, vital signs assessment.
Atropine 1 mg IV bolus, repeat prn up to 3 mg total dose.
Supportive Care:
24 - hour restriction from intense exercise.
Acclimatization plan before returning to play.
Change wet clothes, stay hydrated with electrolytes, moderate room
temperature, and loosen clothing.
Ancillary Test:
12 - lead electrocardiograms (ECG).
Social Determinants of Health and Health Promotion:
Address hyperglycemia from a fast-food diet.
Obesity as a risk factor for heat-related illness requires nutritional
intervention.
Patient Education:
Explain signs and symptoms for early recognition.
Encourage consumption of sports drinks or water.
Educate on a diet to prevent weight gain.
Provide information on signs and symptoms of low blood pressure.
Follow-Up/Disposition:
Referral to cardiac consult.
Follow up in 1 to 2 weeks.
Immediate 911 call if bradycardia symptoms persist.
Gradual return to activity as tolerated.
Excuse from school sports for 5 days, return if symptom-free.
Discussion Question 1: Missed Questions in History Collection
Two crucial questions I failed to ask were:
1. Does the pain in your chest radiate somewhere else? Where?
2. Any change in your chest pain since it began?
I did not delve deeply into the patient’s chest pain complaint. Goolsby (2015)
emphasizes that any chest pain should be thoroughly investigated. Key aspects
include determining active cardiac symptoms, inquiring about current
medications, comorbidities, and exploring the duration, character, and radiation
of chest pain (Goolsby, 2015). These omissions limit a comprehensive evaluation
of potential cardiac involvement. iHuman case: Rand Hall V3 PC.
Discussion Question 2: Errors in Physical Exam Collection
Two errors in my physical exam were:
1. Failure to assess and measure jugular venous pressure (JVP).
2. Incorrect lung sound documentation.
JVP measurement is crucial in differentiating heart and lung diseases, indicating
conditions like heart failure or pulmonary hypertension (Buttaro et al., 2017).
Correct documentation of adventitious breath sounds, including descriptors of
pitch, amplitude, and timing, aids in determining their cause (Goolsby, 2015).
These errors compromise the accuracy of cardiopulmonary assessment. iHuman
case: Rand Hall V3 PC.
Discussion Question 3: Key Finding — Tactile Fremitus
One key finding was tactile fremitus. Tactile fremitus assessment involves
palpating symmetrical areas while the patient speaks. Increased fremitus
suggests conditions like pneumonia, tumor, or fibrosis, while decreased fremitus
indicates abnormalities like pleural effusion or pneumothorax (Goolsby, 2015).
This finding guides further assessment of lung conditions, aiding in the
identification of underlying issues. iHuman case: Rand Hall V3 PC.
Discussion Question 4: Missed/Incorrect Category in Assessment
Identification
I listed pneumonia without specifying it as community-acquired pneumonia.
This type, caused by Streptococcus pneumoniae, Staphyloccus aureus, and
Haemophilus influenzae, exhibits symptoms such as cough, fever, malaise, chills,
and chest discomfort (Goolsby et al., 2015). Recognizing community-acquired
pneumonia is vital for appropriate management and understanding the likely
causative pathogens.
Discussion Question 5: Missed Differential Diagnosis — Angina
I missed angina as a differential diagnosis. Bickley (2017) emphasizes the
importance of considering cardiac origin in chest pain. Eliciting attributes
through OLDCART aids in understanding the cause of chest pain, and angina
should always be part of the list of potential diagnoses in adults. This omission
limits a comprehensive assessment of cardiac involvement.
Week 7 iHuman Assignment – 18 year old male 6’0” 220 lbs. Reason for encounter: Passed out “I passed out at football practice. My trainer thinks its because of the heat index being 100 and that I didn’t drink enough. We have a big game tomorrow so I just need to make sure I can play.” Senior in high school When did you pass out? – Just today Did you hit your head? Did you lose consciousness? – A few seconds LOC. How were you feeling prior to passing out? – During our afternoon practice we ran our 2 mile laps and I noticed that I was struggling and my legs were hurting. All of the sudden I seemed to lose my hearing, noticed my vision changed. It was like just black and white, no color, then it coned down to a pinhole and next thing I remember, I am down on the track looking up at the trainer.
Any preceding symptoms or aggravating factors? – No shortness of breath before fainting. Muscles have been sore this week from working out. How did you feel when you regained consciousness? Did not feel confused. Everyone was standing around me and looking at me. It took my a few seconds to recognize where I was. I didn’t remember falling, but after they told me I remembered the weird feeling leading up to the fall, I guess. I wasn’t out for long. Severity – Did you feel any pain? Was the episode witnessed? – Yes. Dad (Ken Brown) reports that when he got to the field it had just happened. The trainer said that she noticed he had just stopped, stumbled a bit, and then went down. All happened about an hour ago. Have you ever passed out before? No first time today. Patient reports sweating like crazy today.
- Headache that started an hour into morning practice ( 6 hours ago.) Denies any trauma. 8/10 pain at lunchtime and now 3/10 pain. No come/go. Usually does not suffer from headaches. Football is the only sport he plays now. Patient used to play lacrosse, but quit 2 years ago. He started two practices a day this week. Reports sleeping 6-8 hours per night Do you have any ongoing medical issues? Only allergies and the things that were told to patient at last visit. Any previous surgeries or hospitalizations? No medical, surgical, or dental procedures. Any allergies? Seasonal stuff, like grass and mold makes him sneezing and have a runny nose, which is much worse in the fall. Any past injuries? (concussions, sprains, or broken bones) Are you taking any medications (prescription, over the counter, dietary supplements)? No changes in medications. Patient reports takin an antihistamine and creatine. Any medical problems that run in your family? Dad reports overweight, high blood pressure and depression. Whatever is listed in his chart. Does your heart every race or skip beats during exercise? No palpitations, Have you had headaches with exercise? No Do you get lightheaded or feel shorter of breath than expected during exercise? No Do you get tired or short of breath more quickly than your friends during exercise? No Any chest pain upon exertion? No chest pain, discomfort or pressure. No pain/pressure/dizziness with exertion or getting angry. Have you ever had a seizure? Dad reports no seizures. Any problems with your eyes or vision? (seeing sports in your visual field) – Reports no problems with eyes. No troubles with vision. No distortions or loss of central vision. Do you worry about your weight?
Are you trying to or has anyone recommended that you gain or lose weight? Reports no diets in the last year. Does not keep track of how much he drinks. Patient reports that he drank Gatorade when the coaches gave him some. He did not drink during normal water breaks today. Does not feel dry, dehydrated, or drained of moisture. +Exercising Vigorously. Summer football work started a month ago. He reports starting lifting weights and running, sprints and wearing gear. Are you on a special diet or do you avoid certain types of foods? Any recent infections? No recent acute or chronic infections. Reports overall health is pretty good. No problems with fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, or night sweats.
- Drinks alcohol at parties. Sometimes he gets drunk, but not every day or anything. Never caused any problems. He reports that it is a way to let loose from game stress on weekends with his football buddies. +Smoking weed occasionally on the weekends. +Vaping. 1 cartridge a week +Reports smoking for a year to two Chief Complaint: “Passed out at football practice” HPI: Patient is an 18 year-old Caucasian male high school senior who reports to the clinic with his father. Patient states, "I passed out at football practice. My trainer thinks it's because of the heat index being 100 and that I didn't drink enough." He states that incident occurred about an hour ago and prior, he was running 2-mile laps and noticed his legs were hurting. Patient reports loss of hearing and vision changes. Episode was witnessed by his trainer who reports that she noticed him stop, stumble a bit, and then went down. Patient lost consciousness for a few seconds. Patient does not report any preceding symptoms. He did not remember falling. Muscles have been sore throughout the week. Patient reports a headache that began an hour into his practice. Denies any head trauma. Patient has never passed out before. No past injuries. Vigorously exercising with his summer football that involves lifting weights, running, sprints, and wearing gear. Patient reports recently starting two-a-day practices. General: Patient is an overall healthy 18 year-old male who plays football. Patient reports excessive sweating today. No recent acute or chronic infections reported. HEENT/Neck: Patient reports loss of hearing and vision changes, prior to passing out. He describes the vision changes just black and white, without any color, then it coned down to a pinhole. Reports no problems with eyes. No trouble with vision. No distortions or loss of central vision. Cardiovascular: Denies any palpitations. No chest pain, discomfort, or pressure. No pain, pressure, or dizziness with exertion or getting angry. Patient denies feeling lightheaded during exercise. Respiratory: No shortness of breath before fainting. Patient denies feeling short of breath during exercise. Gastrointestinal: No diets in the last year. Does not keep track of how much he drinks. Patient did not drink during normal water breaks at football practice today, and remembers drinking a Gatorade that one of the coaches gave him. Does not feel dry, dehydrated, or drained of moisture.
Gastrourinary: Deferred. Musculoskeletal: Reports sore muscles. Exercising vigorously. Neurologic: Patient's father reports no seizures. Patient reports a headache that started about 1 hour into his football practice (roughly 6 hours ago). Reports 8/10 pain at lunchtime and 3/10 pain now. Patient normally does not suffer from headaches. Denies any trauma. Integumentary: Deferred. Psychiatric: Deferred. Endocrine: Deferred. Hematologic: Deferred. Allergic/Immunologic: Patient reports seasonal allergies to grass and mold, which cause him to sneeze and rhinitis, which is worse in the fall. Past Medical History: PMH: Allergic Rhinitis, Elevated BMI Hospitalizations/Surgeries: No medical, surgical, or dental procedures reported. Preventative Health: Patient reports sleeping 6-8 hours per night. Medications: Patient denies any prescription medications. He reports taking over-the-counter antihistamines and supplement of creatine. Allergies: Patient denies any allergies to medications. He reports seasonal allergies to grass and mold, which cause him to sneeze and rhinitis that is worse in the fall. Social History: Patient drinks alcohol at parties and endorses that sometimes he gets drunk, but it's not a regular thing. His drinking has never caused any problems. Patient states it is a way to let loose from game stress on weekends with his football buddies. Patient admits to smoking for about 1-2 years. He smokes weed occasionally on the weekends and vapes 1 cartridge a week. Family History: Patient's father reports Obesity, Hypertension, Depression, and whatever else is previously listed in his chart. Previous Records indicate: Natural Siblings: Environmental Allergies Natural Mother: Obesity, Depression Natural Father: Environmental Allergies, Hypertension Maternal Grandfather: COPD, Diabetes Mellitus Type II, Hypertension Maternal Grandmother: Alzheimer's Disease Paternal Grandfather: Unknown Paternal Grandmother: Unknown Before passing out, did you feel dizzy, cold, clammy, weak, stressed, anxious or nauseous? Dehydration, overworking, Exercising or woking too hard in the heat, skipping multiple meals, standing too fast, hyperventilating, and using drugs/alcohol can chouse a person to pass out
Any neurologic disorder (ex: seizures, drop in blood pressure, diabetes, taking certain medications like diuretics, ca channel blockers, narcotics, and medications for allergies continaing antihistamines and ACE inhibitors) Abnormal History or Complaints Key Findings List Physical Examination: Patient’s clothes are drenched in sweat. His skin is cool and clammy to touch. Appears slightly pale. No bruising or lacerations noted. Normal skin turgor. Left & Right Pupils are normal reactive. Visual Acuity with Snellen pocket card: Right Eye 20/20 Left Eye 20/ Ears: Normal appearing external structures. No deformities or edema. No discharged noted. Tympanic membranes – bilateral light reflex, no hemotypanum. Hearing tested – no hearing deficits. Normal Weber and Rinne tests. Respiratory: Bilateral lung fields clear upon auscultation. Musculoskeletal: Normal bulk and tone. No rigidity. Strength is 5/5 bilaterally. Neurological: MMSE: 3/3 registration and recall. Attention intact. Names 2/2 objects accurately. Able to follow multistep command. Spatial and executive function intact on drawing task. Score 30/30. Balance test normal. No dysmetria (able to perform smooth, coordinated, upper extremity movements). Normal point-to-point test legs (heel down shin). ROM is normal and equal bilaterally. HPI: Onset: Location/Radiation: Duration: Character: Aggravating Factors: Relieving Factors: Timing: Severity: ROS (based on questions you asked)
- Loss of consciousness +Orthostatic Hypotension +Nausea
- Obesity
- Sweating +Headache +Lightheadedness +Antihistamine use +Muscle cramps/Leg Pain +Tachycardia +Capillary Refill of 3 second +Dry mucous membranes +Decreased Urination +Substance Abuse: Nicotine, THC, Alcohol Order Tests (for top 2 diagnoses) Review Results Select Final Diagnosis Management Plan Template Primary Diagnosis with ICD-10 Code:
- Heat Exhaustion (T67.5XXA) - This diagnosis is most consistent, given the high heat index of 100 and patient did not consume enough fluids while at football practice. Patient has been exercising vigorously with the summer weather and football gear on. They have been having two-a-day practices and patient had passed out. Prior to this incident, patient reports symptoms of headache, lightheadedness, and nausea. His physical examination revealed hypotension and tachycardia, which supports this diagnosis. Patient had excessive sweating and admits to not hydrating well. Additionally, patient has predisposing factors including obesity, alcohol use, smoking/vaping, use of antihistamines, and poor heat adjustment. Differential Diagnoses with Rationale:
- Wolff-Parkinson-White Syndrome (I45.6) – Wolff-Parkinson-White Syndrome is a congenital cardiac preexcitation disease that results from abnormal cardiac electrical conduction through an accessory channel and may cause symptomatic and lethal arrhythmias. When sinus rhythm is present, the EKG
demonstrates the WPW pattern or preexcitation that is characterized by a short PR interval, prolonged QRS, and an initial slurring upstroke wave. Patients with a WPW pattern who never developed an arrythmia will present as asymptomatic and their history and physical examination will be unremarkable. Patients with WPW pattern who develop a tachyarrhythmia will experience symptoms such as palpitations, chest pain, dyspnea, lightheadedness, syncope, collapse, and sudden death. WPW pattern can be diagnosed with a standard EKG and patient’s EKG revealed Sinus Tachycardia, which can exclude Wolff-Parkinson-White Syndrome as a primary diagnosis (Chhabra, Goyal, & Beham, 2022).
- Exercise Related Syncope (R55) – A possible diagnosis to rule out would be exercise related syncope. Asudden and brief loss of consciousness is known as syncope, which is brought on by cerebral hypoperfusion. There are three types of syncope: cardiac, orthostatic, and neurally induced. All patients who experience syncope are given a thorough medical history, physical examination, and electrocardiogram as part of their initial evaluation. Up to 50% of patient may have a diagnosis after the initial assessment, which also provides for short-term risk classification. Neuroimaging and laboratory tests have limited diagnostic yields and should only be requested when clinically necessary. (Rusner, Gauer, & Houser, 2017).
- Orthostatic Hypotension (I95.1) – Another diagnosis to consider is Orthostatic Hypotension. It is defined as a drop in blood pressure of at least 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing from a lying down position or assuming a head-up position of at least 60 degress during tilt table testing. Common symptoms include headache, dizziness, shoulder and neck pain, vison abnormalities, dyspnea, and chest pain, which occur from insufficient physiologic compensation and organ hypoperfusion. Depending on the cause and heart rate response, orthostatic hypotension can be categorized as neurogenic of non-neurogenic. Reducing symptoms and raising quality of life are the main objectives of treatment for orthostatic hypotension (Kim & Farrell, 2022). This could be a possibility, but heat exhaustion is more consistent with the high heat index, intense football exercises, inadequate hydration, and loss of consciousness.
- Vertigo/Dizziness (R42) – Vertigo frequently presents in both the primary car setting and emergency room. It is described as a sensation of motion, most frequently circular motion, and it is a sign of vestibular dysfunction. Vertiginous sensations must be distinguished from other types of dizziness, such as lightheadedness, which is most frequently linked to presyncope. Anyone can get vertigo. Middle ear pathology is most frequently the cause in younger people (Stanton & Freeman, 2022). Patient had reported loss of hearing prior to passing out, but his ear examination upon assessment was normal. He did not report any dizziness.
- Sports Related Concussion (S06.0X9A) – Youth playing contact sports face a significant public health risk from sports-related concussion. After a concussion from athletics, dizziness is frequently observed. Concussion-related forces may damage a number of anatomical structures, including the cervical spine, vestibular system, and central nervous system, all of which is sufficient to produce vertigo. A direct blow to the head, face, neck, or any part of the body that transmits an impulsive force to the head results in a concussion. A history is regard as the single most crucial factor in making an accurate diagnosis (Reneker et al., 2015). This can be ruled out because the patient did not hit his head when he passed out. Medications: (OTC, Dosage): Tylenol 650 mg PO every 4-6 hours as needed for headache Anti-nausea medications as needed (ex: Zofran, Reglan)
Education:
- Rest in a cool place. Air conditioning or sitting in front of a fan is preferred.
- Allow body temperature to cool down - try cooling measures to bring temperature down (ex: cool shower, soak in cool bathe, put towels soaked in cool water against your skin, cooling blankets)
- Drink cool fluids.
- Loose, lightweight clothing in the heat. Avoid alcohol, smoking, and vaping Ancillary Tests Need, Referrals, Follow up: No ancillary tests or referrals needed. Follow up if symptoms persist or reoccur. Social Determinants of Health to Consider, Health Promotion, & Patient Risk Factors
- Discuss smoking cessation and the long-term health effects of smoking marijuana and vaping
- Discuss alcohol-related harm in youth and how teenage drinking can increase the likelihood of damage to a growing brain
- Safety Screening
- Depression Screening
- Dietary Counseling
- Exercise Management and Regimen
- Discuss healthy sleep habits